History and Physical Examination

History and Physical Examination

  • Submitted By: cwalker0031
  • Date Submitted: 01/13/2009 6:49 PM
  • Category: Business
  • Words: 595
  • Page: 3
  • Views: 1581


Patient Name: Gerald Edwards

Hospital No.: 11058

Room No.: 481

Date of Admission: 07/15/2008

Admitting Physician: Catherine Baker, MD

Admitting Diagnosis: Complications of known Diabetes Mellitus.

HISTORY OF PRESENT ILLNESS: This is a 53-year-old black individual, a patient of Dr. Shelton who has diabetes for at least six months but he thinks it has been longer than that. He says his last known blood sugar was in the 300’s. He presents in the ER today with a foot ulcer since January of this year. He stated that it started with blisters where he had soaked his feet too long in hot water. He has had no eye examination for two years. There has been no surveillance of chronic complications of diabetes.

PAST MEDICAL HISTORY: Allergies: No known allergies. He has had measles, mumps, and chicken pox. Denies scarlet, rheumatic, or typhoid fever. No epilepsy, cancer, tuberculosis, tuberculosis contact, STD’s, AIDS, or whooping cough. In 2000 he was admitted to the hospital for an anxiety attack. At that time he weighed 382 pounds. He had a TNA at 5 years of age. He had all his teeth removed ten years ago. He had a skin graft to his right foot ulcer in March of this year.

CURRENT MEDICATIONS: 1) Trental 400 mg p.o. t.i.d. with meals 2) Cipro unknown dosage

FAMILY HISTORY: Mother died at age 73 from cancer of the left breast. Father died at age 56 from alcoholism. He has two brothers, 42 and 45, both alive and well. He had two sisters, one of whom died at age 18 months from encephalitis. The other sister died at age 53 from carcinoma of the lungs, secondary to smoking. He has three children, a 19-year-old son, a 24-year-old son, and a 27-year-old daughter, all alive and well. He has a first cousin with diabetes. Other than that there is no family history of diabetes.

SOCIAL HISTORY: He smokes two packs of cigarettes per day. He drinks a rare beer. He is divorced and lives alone. He is Protestant, has a tenth...

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